Crisis Intervention in the acute Phase after Trauma: the

Crisis Intervention in the acute Phase after Trauma,
the client´s subjective needs
Acute Interventions after sudden loss: the families´
subjective view
B. Juen, E. Mohr, Siller, H., Gmeiner, V.
University of Innsbruck
Stage or phase models of grief
Stage models assume a detmermined course of grief like:
disbelief, intensive emotions, acceptance
In working models of grief, the tasks that have to be
accomplished are also conceptualized in phases like:
realization, working through emotions and reuptake of
emotional life
Phase or stage models do not have an empirical basis
Research example Maciejewski et al analysed a group of 233 grieving persons and found that
disbelief was not the dominant response in the beginning, acceptance was most dominant in
all phases and yearning was the most prominent negative grief indicator in the first months.
Over time, disbelief and yearning decreased and acceptance increased
Coping models of grief
Today most reseachers prefer coping models of
grief to phase or stage models
Grieving persons have to cope with new and
overwhelming emotions as well as with new life
circumstances (Znoj, 2007)
Research example, Berne study on parental grief: If this process is
completed in a positive way, persons may be more able to cope with
extreme negative emotions than others (Znoj, 2006)
Grief therapy
Loss is a life-event that has a specific, even biologically determined
reaction course and takes time. According to Znoj (2004,2006)
therapeutic help is not always needed and does not shorten the
reaction. It may even hinder the natural healing process (“too much
grief”)
Psychotherapy only works when the bereavement has become
complicated (e.g. Shear et al., 2001, Wagner et al. 2005)
“Thus it must be stated ...that there can be no justification for routine intervention
for bereaved persons in terms of therapeutic modalities -- either psychotherapeutic
or pharmacological -- because grief is not a disease.” (Raphael, Minkov & Dobson,
2001)
Therapy means interventions that shall help to confront oneself with
the difficult aspects of the loss. This may be useful in complicated
grief but too confrontative if grief is normal.
But what kind of support is effective in the acute phase if not
therapy?
Acute Psychosocial Interventions for grieving families
In lower Austria two support systems are active for families
after the sudden death of a family member.
1.
Crisis Intervention teams consisting of specially trained emergency
personnel come to the site immediately after the event (if the
family wants it) and support the family through the very first hours
(this is paid by the red cross and other NGOs which provide the
service)
2.
In the more severe cases the Acute team consisting of
psychologists and psychotherapists can come into the family up to
five times after the event to give immediate psychological and
psychosocial support (this service is paid by the government)
The Study about the work of the Acute Team
In a study using a mixed method approach the following
questions were analysed
Quantitative data analysis
Which Risk factors can be identified in the families?
Which resources can be identified?
Which interventions are used by the team and how are they
perceived by the affected families?
Which risk factors can predict problematic acute reactions?
Which interventions can predict satisfaction?
The Study about the work of the Acute Team
In a study using a mixed method approach the following
questions were analysed
Qualitative data analysis
Which resources are subjectively seen as important by the affected
families?
Which interventions are seen as important?
Which indicators do the affected see for positive and negative
change?
Acute Team Cases Analysed
426 cases of sudden death were analysed in a quantitative manner
376 cases were documented by narrative protocols and analysed by
qualitative content analysis, 15 of which were analysed in a detailled
manner.
In these cases 1194 individual persons were supported. In these
cases it is not possible to collect data about individuals because
families/groups are in the focus of the interventions. The events were
in most cases sudden death of a family member by suicide, Illness or
accident
The families/groups received a one to three time acute crisis
intervention at their home by psychologists/
psychotherapists of the Acute Team in Lower Austria
Quantitative Results
(see poster session)
Risk factors stem from the situation, the person, previous trauma or
disorder
Problematic acute reactions like severe dissociation, panic attacks,
severe forms of helplessness etc. can be seen rather often in the
familes supported
Of the resources the most prominent are the social resources
The team uses interventions according to the Hobfoll principles
(safety, connectedness, calm, self/colelctive efficacy and hope)
Most prominent are the interventions promoting self (colllective)
efficacy and calming interventions
Only the situational factors can predict problematic reactions in the
acute phase (especially violent events and accidents with near death
situations)
Satisfaction can best be predicted by calming interventions
Qualitative results
Subjectively perceived resources
Being able to talk to somebody from outside
Connectedness with family and friends
Social integration (to have a network of friends, school,
broader social network)
To be able to take responsibility for the family
Personal resources (creativity and rituals)
Being able to talk to someone from outside
To talk about the death can bring stress reduction
It can also enhance the feeling of self efficacy and saftety
if the person to whom you talk can be trusted and is able
to give psychoeducation
Safety can be enhanced if the person realises that the
horrible event which cannot be fully put into words can
be shared with another person who bears witness to it
(especially in violent trauma this is an important factor)
In the words of the affected persons
To be able to talk about difficult emotions like guilt feelings
and fears
To have a person listening who is objective and comes from
outside the family
To talk to family and freiends is often only done in small pieces
whereas here they feel they can take their time and talk about
the whole story in detail
They find it important that they are given time and space to
think about the event and „summmarize“ the things that have
happened
They feel they can bring order into their thoughts and feel less
lonely
Connectedness and social support
To feel connected to others espeically family and friends is one
of the most important resources in these situations
Also the feeling to be part of a broader social network is
perceived as very important
To be able to take responsibility for the family is an important
factor in self and collective efficacy and helps the affected
persons to be not only on the receiving end of social support.
This includes not talking about certain aspects of the event
with the family in order to protect them (especially after
violence, see also Yehuda et al 1998)
Personal resources
Creativity is seen as important by the affected persons.
They write letters and poems, they draw pictures
They engage in a variety of individual and collective
rituals that help to work through the feelings of loss and
to keep contact to the deceased (see also Schwaiger,
2011, Duffek, 2012)
Functions of rituals
(Schwaiger 2011)
Rituals can help to fulfill needs that cannot be fulfilled by
the social environment
to feel proximity to the deceased, to give the deceased person
space in everyday life, to express ambivalent emorions, to create
order and control….
Personal rituals are not done when others are present
but only in private
Rituals can be realized by actions but soem are done only
by imagination
Rituals can but do not have to contain spiritual elements
Qualitative results: Subjectively important
Interventions
To have an external person who one can trust
To have the possibility to express emotions and enhance
understanding by talking about the event
To be coached through next steps
To have continuity and a certain length of support
Somebody who is really present, interested and attentive
To have enough time (more than one contact)
Support in activating resources
Listening
Getting information about where to get further help and how
to cope with symptoms
In the words of the affected
To be able to talk about guilt feelings and be unconditionally accepted
Getting information about what to do next and how to get further help
To be able to ask questions about any aspects of the event that is
important like, how has he died, did he suffer etc.
The affected persons feel that they become more active by getting
information and advice about how to cope with the new life
circumstances
They appreciate psychoeducation because they learn about their
symptoms and how to cope, they fell more secure
They say that it was especially helpful to again talk about everything
after some weeks and to have a continuity in support from the accident
until four weeks afterwards. They would wish even more contacts.
To be present, interested and attentive: The feeling that somebody cares
Qualitative results: Indicators of positive change
Uncontrollable thoughts about the deceased/the event have
decreased
Active and contolled working through becomes possible: death is a
reality now and acceptance is enhanced, rituals are done to
understand and mark the next step
Mood and climate within the family are better now, tension has been
reduced
Mood of the person has become better, he/she feels stronger, is
more calm
To talk about loss and guilt feelings becomes possible
Fear is diminished
Normal everyday life can be started again
„Old“ rituals like how to celebrate christmas or birthdays are
rearranged
Qualitative results: Indicators of negative change
These stem mostly from the grieving process but also from
the necessity of role change in the family after a loss as well
as from difficult reactions in the social environment
(negative social support) or from previous family conflicts
New conflicts in the family
Misunderstandings and lack of understanding from the outside
world
Old conflicts from the past intervene with the acute trauma
Mood decreases and grief gets worse (often as a normal phase in
the grieving process)
In the words of the affected
There is not such a big tension any more
Grandma can now talk about her loss and guilt feelings
I am feeling stronger and better now
Old conflicts between our family and the family of our
uncle become mixed up with our present story
We start to go on with our lives (we meet friends again,
we go out again…)
In the words of the affected
Grief is becoming worse when you realize that he is
never coming back
You have to let him go
Especially christmas is a very difficult time
Conclusions: Supporting the normal process of
coping by the following interventions
Listen to the grieving person and support the natural grieving process
1.
•
For the grieving family to be able to talk to an outsider who is present interested and attentive is very
important especially when dealing with difficult emotions
Give information and psychodeducation
2.
•
To get information and psychoeducation is very important in order to be active and feel competent
and able to cope with the extreme negative emotions
Accompany and support understanding in a nonintrusive manner
3.
•
To be able to repeatedly talk about event and deceased person in order to come to a better
understanding is seen as the most important aspect of talk
Promote connectedness
4.
•
To be connected to family and friends but also to a broader social network is seen as crucial
Encourage personal resources and rituals
5.
•
But also personal resources like creativity and rituals are seen as helpful in the grieving process and
can support the coping process
Conclusions
Positive changes are described by the affected persons as
a change from the uncontrollable rumination towards a
more controlled thinking about the deceased and the
event. This process is very similar to what Tedeschi and
Callhoun describe as the pathway to Posstraumatic
Growth
References
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Directions in Psychological Science 18 (6), S. 352–356
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persons. Death Studies 24: 603–610
Schwaiger, E. (2011) Die Funktion von Ritualen nach traumatischen Ereignissen (unveröffentlichte
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